Vascular Lesions In Children Research Articles

Diagnostic approach to hepatic vascular lesions: a paediatric perspective.

The pathological evaluation of hepatic vascular lesions in children requires special consideration. Inconsistent terminology, rarity of pathology specimens and overlapping pathological features between various lesions may pose a serious diagnostic challenge. In this review, we highlight the importance of using the International Society for the Study of Vascular Anomalies (ISSVA) classification scheme to characterise these lesions. Selected entities are discussed, including hepatic vascular tumours exclusively seen in the paediatric age group, hepatic infantile haemangioma and hepatic congenital haemangioma. Vascular malformations, with emphasis on their syndromic associations (venous malformation in blue rubber bleb naevus syndrome) and complications (hepatocellular nodules in Abernethy malformation) are also covered.

Infantile Hemangioma: A Common Lesion in a Vulnerable Population

Infantile hemangioma (IH) is important to all dentists, particularly dentists providing services to pediatric populations, because significant morbidity and mortality can occur from vascular lesions in children. Specialists of the oral cavity have the responsibility to identify patients with IH, a lesion that could be potentially life threatening. We present a case of IH and will provide a narrative review of the most recent literature. We discuss the diagnosis, risk stratification, treatment, complications, and impact on routine dental procedures. A proper diagnosis is crucial as oral and perioral IH are considered high-risk due to the increased risk of ulceration and feeding impairment. Referral to a hemangioma specialist for comprehensive team treatment is optimal. The natural history of IH consists of a long proliferative phase, which manifests as clinically visible growth. As a result of early encounters with patients, the pediatric dentist may often be considered the primary care provider.

Surgical excision of lobular capillary hemangioma with laser under N2O/O2 conscious inhalational sedation in an uncooperative pediatric patient, Frankl class 2: a case report

<p>Here, we report a case of lobular capillary hemangioma (LCH) associated deleterious oral habit on lateral border of the tongue in an anxious child excised under nitrous oxide (N<sub>2</sub>O) sedation using soft tissue diode laser. LCH are rapidly growing vascular lesions and are common occurrence over tongue, but to be associated with deleterious oral habit is an uncommon occurrence. A 9-year-old female child was brought to the dept by her parent due growth on the tongue. The child was quite anxious and displayed negativity towards examination and treatment. The child was classified as Frankl 2 on the behaviour rating scale. A pre-anaesthetic check-up was carried out on the child as it was envisaged to carry out the treatment under inhalational sedation. The anaesthesiologist along with crash cart were present throughout the procedure to cater to any adverse events. The excision was done with 980-nm soft tissue diode LASER to reduce intraoperative haemorrhage, enhance patient comfort and improve postoperative healing. A novel combination of inhalational sedation with soft tissue diode LASER with all necessary precautionary protocols as used in management of this child may be an useful approach for successful and uneventful management. To highlight the importance of proper use of pharmacologic methods in behaviour management as well as surgical techniques for better management of these vascular lesions in children.</p><p><strong> </strong></p>

Vascular lesions in genital lichen sclerosus in pediatric patients.

Lichen sclerosus is a rare, pruritic, mucocutaneous disease affecting mostly the anogenital area. Reports have occasionally associated lichen sclerosus with overlapping vascular lesions. This study explores this association in children. A retrospective study was conducted in the dermatology unit of a pediatric tertiary care medical center. Electronic medical records were searched for patients diagnosed with lichen sclerosus from 2006 to 2019. Review of the cases was performed to identify overlapping vascular lesions and review the clinical course of overlap cases. Of 74 children diagnosed with lichen sclerosus during the study period, five (6.75%) had overlapping vascular lesions and genital lichen sclerosus. Four patients presented with reticular telangiectatic macules and patches (n=4, 5.4%) that appeared at or shortly after disease onset; resolution occurred a few months after treatment initiation. The fifth patient presented with telangiectases that appeared more than 2years after the onset of the first symptoms of lichen sclerosus (n=1, 1.3%). Vascular lesions in children with genital lichen sclerosus are common and have variable clinical manifestations. Early appearance of reticular macules, patches, and papules is a variant of the disease and is followed by prompt resolution of these lesions. Pathogenesis is attributed to structural changes and repositioning of the papillary vascular plexus. These changes may be alarming to parents and therefore must be recognized by physicians to prevent unnecessary concern and investigations.

Posttraumatic cerebrovascular injuries in children. A systematic review.

Posttraumatic craniocervical vascular injuries in pediatric traumatic brain injury (TBI) are rare, and children-specific, evidence-based standards on screening and therapy of posttraumatic carotid-cavernous fistula (CCF), craniocervical artery dissections (CCAD), traumatic aneurysms (TA), and posttraumatic sinus venous thrombosis (SVT) is lacking. The aim of this review is to summarize the data on epidemiology, clinical presentation, and treatment of these traumatic lesions in a systematic manner. We performed a systematic PubMed search for records of CCF, CCAD, TA, and SVT related to pediatric TBI published until June 2019. After screening 2439 records, 42 were included in the quantitative analysis. Incidences for CCAD in blunt TBI were 0.21% (range 0.02-6.82%). 11.7% (range 1.69-15.58%) of pediatric aneurysms were found to be traumatic of origin, whereas 38.2% (range 36.84-40%) of all pediatric SVT were due to blunt TBI. For all of the posttraumatic cerebrovascular pathologies, we found a clear male predominance with 68.75% in CCF, 63.4% in CCAD, 60% in TA, and 58.33% in SVT. Clinical presentation did not differ from the adult population with exception of young child. While there is only recommendation for the therapy of CCAD and SVT in the pediatric population, no such recommendation exists for the treatment of CCF's and TA's, and data from randomized controlled trials is lacking. While these results show that posttraumatic CCF, CCAD, TA, and SVT are rarely encountered in children, misdiagnosis may have potentially drastic consequences due to a longer lifetime burden in the pediatric population. Awareness, early recognition, and prompt initiation of the appropriate therapy are essential to avoid morbidity and mortality. Further studies should focus on the development of clinical and radiological screening criteria of posttraumatic vascular lesions in children.

RASA1/CM-AVM related central nervous system vascular lesions in children

RASA1/CM-AVM related central nervous system vascular lesions in children

Computed tomography depiction of small pediatric vessels with model-based iterative reconstruction

Computed tomography (CT) is extremely important in characterizing blood vessel anatomy and vascular lesions in children. Recent advances in CT reconstruction technology hold promise for improved image quality and also reductions in radiation dose. This report evaluates potential improvements in image quality for the depiction of small pediatric vessels with model-based iterative reconstruction (Veo™), a technique developed to improve image quality and reduce noise. To evaluate Veo™ as an improved method when compared to adaptive statistical iterative reconstruction (ASIR™) for the depiction of small vessels on pediatric CT. Seventeen patients (mean age: 3.4years, range: 2days to 10.0years; 6 girls, 11 boys) underwent contrast-enhanced CT examinations of the chest and abdomen in this HIPAA compliant and institutional review board approved study. Raw data were reconstructed into separate image datasets using Veo™ and ASIR™ algorithms (GE Medical Systems, Milwaukee, WI). Four blinded radiologists subjectively evaluated image quality. The pulmonary, hepatic, splenic and renal arteries were evaluated for the length and number of branches depicted. Datasets were compared with parametric and non-parametric statistical tests. Readers stated a preference for Veo™ over ASIR™ images when subjectively evaluating image quality criteria for vessel definition, image noise and resolution of small anatomical structures. The mean image noise in the aorta and fat was significantly less for Veo™ vs. ASIR™ reconstructed images. Quantitative measurements of mean vessel lengths and number of branches vessels delineated were significantly different for Veo™ and ASIR™ images. Veo™ consistently showed more of the vessel anatomy: longer vessel length and more branching vessels. When compared to the more established adaptive statistical iterative reconstruction algorithm, model-based iterative reconstruction appears to produce superior images for depiction of small pediatric vessels on computed tomography.

English

BACKGROUND: Traditionally there has been much debate about vascular lesions being developmental malformations or types of neoplasia. Vascular tumours are believed to result from developmental errors that occur at 4-10 weeks of gestation. Most cases are sporadic. Vascular malformations result from abnormal sized or abnormal number of vascular structures. These malformations usually manifest as cutaneous birthmarks and have had a number of classifications, producing a range of confusing terms. AIMS AND OBJECTIVES: To study the incidence, classification and spectrum of various vascular lesions in children with a clinicopathological perspective. MATERIAL AND METHODS: The present retrospective study was undertaken at the Department of Pathology, Paediatric Referral Hospital, during the period from June 2009 to May 2011. About 44 patients of the paediatric age group were analysed for clinical details and pathological diagnosis. Vascular lesions were classified histopathologically according to International Society for the Study of Vascular Anomalies (ISSVA) classification broadly into two groups, mainly vascular tumours and malformations. RESULTS: Of the 44 cases reported in our study, vascular lesions were commonly seen in infants. The male to female ratio was 1:2.1. Most common site involved was head and neck region (73%). 39 cases were classified as vascular tumours which included haemangiomas and 5 cases classified as vascular malformations which included lymphangiomas. CONCLUSION: Vascular lesions though clinically diagnosed only as haemangiomas, represent pathologically varied entities. These lesions when present in infants and in functional areas, their precise diagnosis by the pathologists makes a significant difference to the management of these simple looking vascular lesions of the children.

Vascular and Perivascular Lesions of Skin and Soft Tissues in Children and Adolescents

Vascular anomalies in children and adolescents are the most common soft tissue lesions and include reactive, malformative, and neoplastic tumefactions, with a full spectrum of benign, intermediate, and malignant neoplasms. These lesions are diagnostically challenging because of morphologic complexity and recent changes in classification systems, some of which are based on clinical features and others on pathologic findings. In recent decades, there have been significant advances in clinical diagnosis, development of new therapies, and a better understanding of the genetic aspects of vascular biology and syndromes that include unusual vascular proliferations. Most vascular lesions in children and adolescents are benign, although the intermediate locally aggressive and intermediate rarely metastasizing neoplasms are important to distinguish from benign and malignant mimics. Morphologic recognition of a vasoproliferative lesion is straightforward in most instances, and conventional morphology remains the cornerstone for a specific diagnosis. However, pathologic examination is enhanced by adjunctive techniques, especially immunohistochemistry to characterize the type of vessels involved. Multifocality may cause some uncertainty regarding the assignment of "benign" or "malignant." However, increased interest in vascular anomalies, clinical expertise, and imaging technology have contributed greatly to our understanding of these disorders to the extent that in most vascular malformations and in many tumors, a diagnosis is made clinically and biopsy is not required for diagnosis. The importance of close collaboration between the clinical team and the pathologist cannot be overemphasized. For some lesions, a diagnosis is not possible from evaluation of histopathology alone, and in a subset of these, a specific diagnosis may not be possible even after all assembled data have been reviewed. In such instances, a consensus diagnosis in conjunction with clinical colleagues guides therapy. The purpose of this review is to delineate the clinicopathologic features of vascular lesions in children and adolescents with an emphasis on their unique aspects, use of diagnostic adjuncts, and differential diagnosis.

Carotid Artery Stiffness as an Early Marker of Vascular Lesions in Children and Adolescents With Cardiovascular Risk Factors

The availability of a noninvasive marker of vascular lesions that enables their detection in the preclinical phase would be of great benefit for cardiovascular disease prevention. The aim of this study was to investigate the usefulness of a range of indices of arterial wall stiffness in the common carotid artery, as derived using high-resolution Doppler ultrasonography, for identifying vascular damage in children with risk factors. The study involved 99 children (age, 8-16 years) divided into two groups: 65 had cardiovascular risk factors (45 obesity, 20 dyslipidemia) and 34 were controls. Family histories of cardiovascular risk factors and anthropometric and biochemical measurements were recorded. Functional parameters of arterial stiffness (i.e., arterial compliance, elastic modulus, beta stiffness index, pulse wave velocity, and augmentation index) and the intima-media thickness were also measured. Some functional vascular parameters were higher in obese children than controls: there were significant differences in beta stiffness index (P< .02), elastic modulus (P< .001) and pulse wave velocity (P< .01). There was a significant difference in arterial compliance between dyslipidemics and controls (P< .05). No significant difference in intima-media thickness was found between the groups. In obese children, there were positive correlations between body mass index, systolic pressure and triglyceride levels and vascular parameters (i.e., elastic modulus and pulse wave velocity); in dyslipidemic children, triglyceride levels and the same parameters were correlated. Ultrasonographic measurement of arterial stiffness is a sensitive technique that can detect vascular damage in children with cardiovascular risk factors earlier than intima-media thickness measurement.

Head and neck vascular anomalies in children

Vascular lesions are the most common congenital and neonatal abnormalities. The aim of this work is to point out differences between various vascular anomalies, in order to define accurate diagnosis, and to present different therapeutic options now used for the treatment of the vascular lesions in children. According to biological classification described by the work of Mulliken and Glowacki there are two major types of vascular abnormality: haemangioma and vascular malformation. Haemangioma is a distinct biologic tumour entity characterised by rapid endothelial proliferation shortly after birth. The lesion is absent at birth and growth in early infancy, followed by a spontaneous resolution in childhood. Vascular malformations are structural anomalies that have a normal growth rate and endothelial turnover. According to the morphology of the vessels and the flow rate we distinguish: slow-flow and fast-flow vascular malformation. The authors document their personal experience in diagnosis, clinical evaluation, treatment and follow-up of the vascular lesions.

Pediatric Vascular Anomalies: The Role of Imaging and Interventional Radiology

&lt;P&gt;Evaluation of vascular lesions in children remains confusing to many physicians, from primary care physicians to subspecialists, including pediatric radiologists. To many physicians, all vascular lesions in children are either hemangiomas or arteriovenous malformations (AVMs), and many don’t understand the difference between these two vastly different lesions. It is important that we use a standard classification, as first proposed by Mulliken and Glowacki in 1982. Standardizing our nomenclature allows us to communicate effectively with each other. By understanding the pathogenesis of many of these lesions, we are better able to direct patients into proper management and to counsel families about the prognosis for their child.&lt;/P&gt; &lt;H4&gt;ABOUT THE AUTHOR&lt;/H4&gt; &lt;P&gt;James S. Donaldson, MD, is Chairman, Department of Medical Imaging, and Section Chief, Interventional Radiology, Children’s Memorial Hospital, and Professor of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL. Address correspondence to: &lt;a href="mailto:jdonaldson@childrensmemorial.org"&gt;jdonaldson@childrensmemorial.org&lt;/a&gt;. &lt;/P&gt; &lt;P&gt;Dr. Donaldson has disclosed no relevant financial relationships.&lt;/P&gt; &lt;H4&gt;EDUCATIONAL OBJECTIVES&lt;/H4&gt; &lt;OL&gt; &lt;LI&gt;Review the Mulliken and Glowacki classification system for vascular lesions.&lt;/LI&gt; &lt;LI&gt;Discuss the epidemiology and imaging and treatment options for vascular tumors in children.&lt;/LI&gt; &lt;LI&gt;Discuss the epidemiology and imaging and treatment options for vascular malformations in children.&lt;/LI&gt; &lt;/OL&gt;

Diagnosis of Vascular Skin Lesions in Children: An Audit and Review

Vascular skin lesions in children are common, but their management is complicated by the ongoing use of inappropriate and often misleading terms. Inaccurate explanations of the diagnosis and progression of these lesions may cause unnecessary distress. This study describes an audit of vascular lesions in children from one center in which the classification system described by Mulliken and Glowacki was used to establish diagnosis. Seventy patients with vascular lesions attending vascular lesion clinics, miscellaneous plastic surgery clinics and laser lists in the Royal Victoria Infirmary, Newcastle-upon-Tyne, were studied. A proforma was completed using information from the patients and their medical records. The initial diagnosis given to parents was inaccurate in 69% of patients. Furthermore, 53% of parents were given an incorrect account of what to expect with regard to progression of the lesion and the prospect of future treatment. Altogether, in 71% of instances some inappropriate terminology was applied during the course of the child's management. Plastic surgeons were the most accurate diagnosticians. This study highlights the fact that a selection of misleading and erroneous terms is still regularly used in medical practice. The recommended classifications are rarely adhered to and in consequence efficient communications between professionals and families is often lacking.

Hepatic Infantile Hemangioendothelioma with Unusual Manifestations

Hepatic Infantile Hemangioendothelioma with Unusual Manifestations

Understanding Abnormalities in Vascular Specification and Remodeling

Accurate classification, diagnosis, management, and treatment of vascular lesions in children can be hindered by the wide range of clinical presentations and varying clinical course of these lesions. In this issue of Pediatrics , Marler et al1 report novel findings that elevated levels of angiogenesis-related proteins, specifically high molecular weight matrix metalloproteinases (MMPs) and basic fibroblast growth factor (bFGF), can be detected in the urine of children with vascular anomalies and can mark clinical progression of these lesions. These findings suggest that a noninvasive test can be developed to characterize aggressive vascular malformations and tumors and provide additional evidence that antiangiogenic agents may be useful for the treatment of these lesions. To approach diagnosis and management of congenital vascular lesions rationally, an understanding of the basic cellular, molecular, and genetic mechanisms of blood vessel formation is required. Recent advances in the field of vascular biology have contributed to our knowledge of how blood vessels are assembled during early embryonic development. Blood vessel morphogenesis involves discrete steps in continuum that are regulated by specific signaling pathways involving soluble effectors, cytokines and their receptors, proteases, and extracellular matrix (ECM) components. These various pathways control integral events that contribute to the formation of a functional vasculature including endothelial and mural cell (pericyte/smooth muscle cell) differentiation, cell proliferation and migration, and the specification of arterial, venous, and lymphatic fate. Dysregulation of these processes can result in vascular malformations affecting 1 or multiple vascular types including capillary, arterial, venous, lymphatic, or arteriovenous channels. During embryonic development, blood vessels form de novo from endothelial progenitors by the process of vasculogenesis.2 This process has been studied most extensively in the mouse yolk sac, wherein endothelial progenitors are specified in the mesoderm and induced to form an initial capillary plexus by effectors derived from the adjacent … Address correspondence to Josephine M. Enciso, MD, Department of Pediatrics, Texas Children’s Hospital, Feigin Center, 6621 Fannin, FC 530.01, Houston, TX 77030. E-mail: jenciso{at}bcm.edu

Role of stents in congenital heart disease

For more than 10 years, balloon-expandable intravascular stents have become an integral part of treatment for obstructive vascular lesions in children and adults with congenital heart disease. The initial problems with stents, such as sharp edges, rigid frame and unacceptable shortening when over-expanded have been overcome to a large extent with the newer designs. The problems related to delivery of stents, such as stent migration, balloon rupture, flaring of the edges of the stent, rupture of vessels and milking of the stent off the balloon, have also been overcome by newer designs of balloons. The failure of growth of balloon-expandable stents with the growth of the child is managed by redilation with or without additional stenting and newer growth stents. Self-expanding stents are not appropriate for use in growing children due to the limitation of their maximum diameters. The development of biodegradable stents may overcome these disadvantages in the future. Various new developments have recently occurred. Covered stents are ideal for treating acute vessel rupture and in isolating vascular aneurysms. Drug-eluting stents may prevent restenosis, but have not been used in children. Valved stents are a recent innovation for the treatment of regurgitant pulmonary valves.

Association between homocyst(e)ine levels and risk of vascular events.

Homocyst(e)ine is a novel risk factor in vascular disease. First observations of vascular lesions in children with high blood homocyst(e)ine levels due to severe inborn enzyme deficiencies led to the hypothesis that elevated blood homocyst(e)ine levels might be a risk factor for vascular disease. A substantial body of evidence on the role of the homocyst(e)ine in the development of coronary and carotid artery disease, myocardial infarction, stroke, deep vein thrombosis and other disorders has been accumulated over the last 30 years. Cross-sectional and case-control studies provide initial and the strongest support for the hypothesis, followed by results from the prospective cohorts. Infrequent cases of homozygous mutations of the key enzymes in the homocyst(e)ine metabolism chain are able to produce extreme homocyst(e)inemia and early vascular lesions. More frequently, heterozygous enzyme mutations and deficiencies of folate and vitamins B6 and B12 cause mild to moderate homocyst(e)inemia, which is still strongly associated with the increased risk of vascular events. Elevated homocyst(e)ine levels may be effectively managed with adequate folate, B12 and B6 intake in doses comparable to or above FDA recommendations. Whether correction of elevated homocyst(e)ine levels with vitamins is helpful in prevention and treatment of vascular events remains unknown and is under investigation in ongoing clinical trials (VISP, VITATOPS). No consensus on homocyst(e)ine management is available at the present time.

Bridge stents in the management of obstructive vascular lesions in children

T most frequently used stents in the pediatric population to date are Palmaz stents. Although Palmaz stents are useful, several disadvantages, namely, the need for a large delivery sheath, balloon rupture, and stent displacement, exist. In addition, longitudinal rigidity of the stent makes it difficult to traverse tortuous course. To circumvent some of these problems, we used bridge stents. These are balloonexpandable, flexible biliary/peripheral stents manufactured by Medtronic AVE (Santa Rosa, California). The purpose of this presentation is to describe our experience with off-label use of these stents in an attempt to evaluate the feasibility, safety and effectiveness in the management of vascular obstructive lesions in children. • • • All patients who had bridge stents implanted for treatment of vascular obstructive lesions in children during a 9-month period ending July 2000 are included. There were 8 children with branch pulmonary artery stenosis (BPS), 2 with postoperative aortic recoarctation, and 1 with postsurgical superior vena caval (SVC) stenosis. The stent is made up of stainless steel (2 mm in length) sinusoidal elements connected together by laser fusion. The sinusoidal elements are designed to form elliptorectangular struts, and this geometry provides strength and resists failure under pressure. The dual-helical, laser-fusion pattern of the elements provides for longitudinal flexibility. During mounting of the stent on the balloon, an elegant stent retention mechanism is used by “pillows” created by a combination of heat and pressure so that the balloon material fills in the space between the struts of the stents along its entire length. The stents are manufactured in sizes 6 to 10 mm in diameter in 1-mm increments and with lengths of 28, 40, and 60 mm. There is minimal foreshortening at the time of stent expansion/deployment. After clinical, 2-dimensional and Doppler echocardiographic and/or quantitative pulmonary perfusion scan (for BPS cases), data indicated significant obstructive lesions, and cardiac catheterization was undertaken to confirm the diagnosis and to consider stent placement. Informed consent was obtained from parents for off-label use of the bridge stents. Conscious sedation was obtained with intramuscular injection of a sedative mixture (meperidine hydrochloride, promethazine hydrochloride, chlorpromazine) and intermittent intravenous doses of medazolam and fentanyl. Initially, peak pressure gradients across the stenotic site and selective biplane cineangiography to demonstrate the stenotic lesion were obtained. An arterial line was placed to monitor pressures and blood gas values during the procedure. Heparin 100 U/kg was administered intravenously. Activated clotting times were monitored and maintained between 200 and 250 seconds by administration of additional doses of heparin, as needed. Access was obtained percutaneously via the femoral vein (n 5 7), internal jugular vein (n 5 2), or femoral artery (n 5 2). With the aid of a multi A-2 catheter (Cordis, Miami, Florida) and a floppy-tipped Benston guidewire (Cook, Bloomington, Indiana), the stenotic lesion was crossed. The Benston guidewire was replaced with an 0.035-inch, extra-stiff, exchange-length Amplatz guidewire (Cook). An 8Fr long Blue Cook sheath (Cook) with a radiopaque marker at the tip was positioned distal to the site of obstruction in 7 patients. In the remaining patients, a short sheath (8Fr in 3 and 7Fr in 1) was used. The selected stent, premounted on a balloon catheter, was advanced over the guidewire but within the sheath and positioned across the site of obstruction. The tip of the sheath was withdrawn proximal to the site of obstruction and the balloon inflated, thus implanting the stent. One or more balloon inflations were performed to ensure apposition of the stent against vessel walls. Pressure pullback recordings across the stent and angiography, usually via a multitrack catheter (Braun, Bethlehem, Pennsylvania) were obtained. Three doses of cefazolin, 25 mg/kg, were administered at 6to 8-hour intervals. The heparin effect was not reversed. On the morning after, aspirin 5 to 10 mg/kg/day as a single daily dose was administered and continued for a 6-week period. Repeat pulmonary perfusion scan (in patients with BPS), chest roentgenogram, and Doppler studies were obtained on the morning after stent placement. Follow-up clinical, chest x-ray, and echo-Doppler evaluations were performed 1, 6, and 12 months after the procedure. Eight patients with BPS were aged 0.4 to 13 years (median 10) with weights ranging from 6.1 to 48.2 kg (median 25). The primary diagnoses were complex congenital heart disease with pulmonary atresia or severe stenosis in 7 patients. Six of these patients had total surgical correction, but had significant BPS. The seventh patient had a prior bidirectional Glenn procedure. The final patient had repair of a diaphragmatic From the Division of Pediatric Cardiology, Saint Louis University School of Medicine/Cardinal Glennon Children’s Hospital, St. Louis, Missouri. Dr. Rao’s address is: Division of Pediatric Cardiology, Saint Louis University School of Medicine, 1465 South Grand Boulevard, St. Louis, Missouri 63104-1095. E-mail: raops@slu.edu. Manuscript received March 1, 2001; revised manuscript received and accepted April 30, 2001.

Does Homocysteine Promote Atherosclerosis?

The hypothesis that homocysteine is atherogenic was proposed more than 30 years ago by Kilmer McCully,1 who observed vascular lesions in children with inherited disorders of methionine metabolism. Since McCully’s pioneering observations in 1969, a large number of epidemiological studies have confirmed that an elevation of total plasma homocysteine (tHcy) is prevalent in patients with stroke, myocardial infarction, peripheral vascular disease, and venous thrombosis.2 A significant association between hyperhomocysteinemia and clinical cardiovascular events has been observed in several large prospective studies, although a few prospective studies have failed to demonstrate this association.2 Nevertheless, hyperhomocysteinemia is now considered by many an independent risk factor for atherosclerotic vascular disease.3 See p 1470 Homocysteine is a thiol amino acid, but only a small fraction ( 15 μmol/L and may be caused by genetic defects, renal insufficiency, certain drugs, or nutritional deficiencies of folate, vitamin B6, or vitamin B12.5 Even a mild elevation of plasma tHcy to levels within the high-to-normal range (10 to 15 μmol/L) may increase cardiovascular risk.2 Because plasma tHcy can often be lowered by oral administration of folic acid or combinations of B vitamins, there is growing enthusiasm for treatment of hyperhomocysteinemia as a strategy for prevention of cardiovascular disease and …

Vascular lesions in children: percutaneous MR imaging-guided interstitial Nd:YAG laser therapy--preliminary experience.

To investigate the use of magnetic resonance (MR) imaging to guide interstitial laser therapy of deep hemangiomas and vascular malformations in children. Sixteen children aged 3 months to 16 years with symptomatic vascular lesions underwent percutaneous laser treatment. MR imaging guidance of the laser applicator and online thermomonitoring with MR imaging were performed with a 0.2-T open MR system. Follow-up studies were performed 2 days and 6 weeks after thermotherapy. Interactive positioning of the laser applicator was possible in all patients. Online thermomonitoring was possible in 122 of 137 therapy spots (89%). There was a good correlation between volumes of coagulated tissue on intraprocedural T1-weighted images and volumes of coagulated tissue on follow-up T2-weighted images. At 6-week follow-up, MR imaging demonstrated a reduction in lesion size in 10 patients (mean reduction, 72%) and an increase in lesion size in two patients (mean increase, 134%). Clinical symptoms improved in 14 of 16 patients (88%). MR imaging-guided laser therapy appears to be a safe and potentially effective minimally invasive treatment for selected children with vascular lesions.